America was profoundly changed on September 11, 2001. The World Trade Centers and part of the Pentagon collapsed. A United Airlines plane crashed into a field near Shanksville, Pennsylvania. The reason: international terrorism. The toll: uninmanageable horror. While terrorism is new in the USA, in many countries around the world terrorism is more common and in fact often practiced. As global terrorism rises, nurses must have discussions about how to treat victims and survivors, how to deal with the toll on nurses who respond to calls for aid, and what can and should be done regarding terrorism.

The contributors to the Volume 7, Number 3 issue of the Online Journal of Issues in Nursing (OJIN) speak to the horror experienced by and to the honor of those nurses who have experienced terrorism and its aftermath. In this column, we address an important but neglected area of nursing—ethics and terrorism. Our discussion of nursing as related to terrorism and ethics will be anchored in three areas: nonmaleficence, beneficence, and distributive justice.

Nonmaleficence

The principle of nonmaleficence is generally defined as not inflicting evil or harm on others. Examples of rules that support this principle are "do not kill" (Beauchamp & Childress, 2001, p. 117) and "do not inflict suffering on others" (Beauchamp & Childress, 2001, p. 117). Typically within health care ethics, the principle of nonmaleficence focuses on issues related to abortion or euthanasia (Veatch, 2003). However, when faced with the tragedy of September 11 and other acts of terror around the world, this principle has an expanded meaning—do not not terrorize or kill innocent people or populations with reckless abandon. No rules of just war, no known religions, and no health care ethics condone such actions.

What damage is inflicted by terrorism? Jameson (2002), a historian, chronicles in painful detail the events of September 11 and what he calls the "grim statistics" (Grim Statistics section, para. 1). In addition to the over 3000 dead and some 6000 injured from the USA and other countries, hundreds of thousands of people suffered physical symptoms and psychological effects. White (2002), citing the American Psychiatric Association (1994), identifies the terrible psychological price that the mass violence of September 11 caused: insomnia, nightmares and flashbacks, loss of concentration, and inability to cope. These symptoms, as well as depression and substance abuse, can last from a few hours to months or years after terrorist attacks. Likewise, Berkowitz (2002), in discussing the public health focus, addressed an "overwhelming sense of fear, depression, and unrelenting stress" (Impact of 911 on Individuals, Families and Organizations section, para.1).

The preceding symptoms and disorders highlight the harm done and the evil of terrorism that precipitated it. Now multiply these problems by the number of terrorist acts in a given week, month or year in countries around the world. Each and every terrorist act egregiously violates the ethical principle of nonmaleficence.

Thus, the global impact of terrorism is real. Nurses must speak out against terrorism wherever it occurs. One strong resounding example of speaking out can be found in The American Nurse (November-December 2001). Here nurses and nursing organizations from around the world decry violence and terrorism. Let us each ask ourselves: Have I as a citizen or member of my profession spoken out against global terrorism? Or do I speak out against terrorism only when it directly impacts me? How many people must die or be injured and where must an attack occur for me to find my voice and take subsequent action?

In her article about September 11 and the preparedness of the New York State Nurses Association (NYSNA), Orr (2002) states: "The association had never contemplated a disaster on this scale. We had planned for fire or other natural disaster involving our headquarters, but we were clearly not prepared to respond to a major community disaster in which the health care system—and nurses—would be a vital resource to be mobilized" (para. 3). Simply put, the NYSNA initially was not prepared to "prevent harm" when the assault on the twin towers occurred.

According to Orr (2002), however, within an hour the NYSNA mobilized an Emergency Response Team (ERT). Among its goals, the ERT facilitated the "doing of good" by establishing communications between the executive staff of the NYSNA and those nurses at the disaster site, managing the influx of nurse volunteer calls from across the nation, centralizing all activities at the NYSNA, providing peer support groups for those nurses suffering great stress, and facilitating public relationships through a web site and broadcast e-mail. The NYSNA also formulated a plan for the future to prevent its lack of preparedness for mass casualties. The plan included eight goals, including the development of a master plan for mass disasters and development of disaster preparedness courses and training. Orr concluded by noting that "Nursing’s organizations have an opportunity and obligation, as part of the profession’s social contract, to identify our appropriate roles in the event of natural or manmade disasters" (Summary section, para. 1). The word obligation (or duty) is not to be taken lightly. It means one must always fulfill the duty unless superseded by an equal or higher duty.

In a like manner, Riba & Reches (2002) illustrate how emergency room nurses in Israel have become proactive and developed policies and education for nurses who are likely to be called in to help in a terrorist attack. They detail nurses’ thoughts and actions with clarity and poignancy. In particular, the authors capture the sense of obligation to help in this rich description: "Nurses described their initial reaction to the news of an attack in terms of deep commitment and compelling need to respond at once regardless of the time of day, what they might have been doing, or the complexity involved in making arrangements for their families" (Call Up section, para. 13).

Both the NYSNA and the Israeli ER nurses have shown how nurses were mobilized for short- and long-term action that fulfilled the requirements for beneficence: doing good, preventing harm, and removing harm. Have you visited the ANA site on "Bioterrorism and Disaster Response" to see what you can do? Have you joined a nurse response team?

Distributive Justice

According to Beauchamp and Childress (2001), "the term distributive justice refers to fair, equitable, and appropriate distribution determined by justified norms that structure the terms of social cooperation" (p. 226). Ethical problems occur with distributive justice when there is competition for scarce resources. The costs inflicted by global terrorist acts combined with costs of preventing attacks is astronomical.

How much money and other resources should be spent on the prevention of terrorist attacks and on the aftermath of such attacks in contrast to other demands for finite resources? According to Jameson (2002), "Especially sobering are the dollar costs of the attacks and the projected expenses of U.S. efforts to control the spread of international terrorism (estimated at $640 billion), just through fiscal year 2003" (Abstract section, para. 1). He states that this cost includes, but is not limited to, lost earnings of the dead; compensation for families of the victims; cleanup efforts; replacement of furniture and equipment; rebuilding the World Trade Centers, surrounding buildings, and damaged areas of the Pentagon; homeland security; anti-bioterrorism plans; military action against terrorists; federal assistance to commercial airlines; federal budget deficits; and loss of historical artifacts. Now multiply these costs across the world. What is the toll of terrorism for any country and its people?

Some countries and persons may challenge the high cost of terrorism and its aftermath in terms of the principle of distributive justice. Questions you may want to reflect and act on include: Is war and its costs ever morally justified? Will violence beget more violence, resulting in the unsustainable cost of war? Who should pay for terrorism and its aftermath? Who will be most affected by the high cost of terrorism and its prevention? Most likely your response to these questions will depend on your value system and on your place in society. Regardless of your stance, your position must be morally justified using ethical principles of justice.

In summary, the ethical principles of nonmaleficence, beneficence, and justice were used to discuss ethics and terrorism within a health care perspective. Nurses play an important role in caring for victims and survivors of terrorists attacks. Now it is time for nurses to reflect, discuss, and speak out on the ethical issues they have faced and may still face as a result of terrorism in their our own country and globally.